Following the implementation of the Health and Social Care Act 2012, a revised Serious Incident Framework was published in March 2013 to reflect the changed structures in the NHS. At the time NHS England committed to review this Framework after a year of operation to understand how well the system was able to implement it. Therefore, over 2014 NHSE reviewed the Serious Incident Framework to ensure that it was fit for purpose and that it supported the need to take a whole-system approach to quality improvement. Following the review an updated Serious Incident Framework was published in 2015.
It links in with the Safeguarding children, young people and adults at risk in the NHS England: Safeguarding accountability and assurance framework’ (SAAF 2015). This document sets out the responsibilities of all individuals working in providers of NHS funded Care and NHS commissioning organisations.
Currently, when Serious Incidents occur within health care, they must be reported via an NHS system called StEIS so that the incident can be identified correctly, investigated thoroughly, and actions can be triggered that will prevent the incident from happening again. However, the current StEIS process does not lend itself to comprehensive tracking, as it is often not clear at the initial reporting stage whether an incident may lead to a statutory safeguarding review. There is also nowhere in the StEIS system to record if there is a safeguarding incident.
NHS England has therefore commissioned NHS Digital to create a new Safeguarding Care Review Tracker system which will provide a facility for recording and capturing lessons/outcomes from all multi-agency Safeguarding Adult Reviews, Domestic Homicide Reviews and Child Safeguarding Practice Reviews. Serious Incidents (SI) which have occurred as a result of harm which may have caused a failure to protect vulnerable children and adults at risk, may also be escalated for one of these statutory safeguarding multi-agency reviews. The Safeguarding Case Review Tracker will enable Clinical Commissioning Groups (CCGs) to submit information about Safeguarding Serious Incidents occurring in their locations and enable them to manage safeguarding incidents that have occurred regardless of the setting, for example those that occur in a public street or park, or in someone’s home etc. The Safeguarding Review Tracker will also be able to identify the number of cases open, themes of incidents and learning from any recommendations.
NHS Digital will provide reports from the Safeguarding Case Review Tracker to NHS England and NHS Improvement (NHSE/I) to support them to successfully deliver their statutory safeguarding duties, roles and responsibilities to all individuals working in providers of NHS funded care settings and NHS commissioning organisations.